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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Professionalism, ethics, and compliance | 9.17% | - Potential DRG creep - Compliance risks indicated by PEPPER - Leading queries - DRG compliance initiatives - Medical record confidentiality - CDI department goals beyond reimbursement |
| Topic 2: Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - HIV infections - Infectious and parasitic diseases - Endocrine, nutritional, and metabolic diseases and disorders - Diseases and disorders of the digestive system - Diagnostic tests as clinical indicators - Diseases and disorders of the skin, subcutaneous tissue, and breast - Pharmaceuticals and disease processes - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Injuries, poisonings, and toxic effects of drugs - Diseases and disorders of the musculoskeletal system - Mental diseases and disorders - Diseases and disorders of the circulatory system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - Diseases and disorders of the hepatobiliary system - Diseases and disorders of the nervous system - Standard medical abbreviations - Diseases and disorders of the kidney and urinary tract - Medications as clinical indicators - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the respiratory system - Diseases and disorders of the blood and blood-forming organs and immunological disorders |
| Topic 3: Communication skills | 9.17% | - Roles and responsibilities of coders working with CDI departments - Verbal versus written physician communication - Physician education forms and tools - Roles and responsibilities of CDI specialists - Reconciling CDI working DRGs with final coded DRGs - Effective and non-confrontational physician communication - Educational presentations for healthcare departments and administration |
| Topic 4: Impact of reportable diagnoses on quality of care | 8.33% | - Patient Safety Indicators - Coded data elements affecting Patient Safety Indicators - Documentation and code assignment impact on mortality index - 30-day mortality measures - Hospital Inpatient Quality Reporting Program - CDI impact on Hospital Value-Based Purchasing - Hospital-Acquired Condition Reduction Program - Hospital Value-Based Purchasing - Mortality reviews and observed/expected ratios - Hospital Readmissions Reduction Program - Quality data from record abstraction and claims data - Healthcare-associated infections and complication codes |
| Topic 5: Official Guidelines for Coding and Reporting | 14.17% | - Secondary diagnosis assignment - AHA Coding Clinic - Official Guidelines for Coding and Reporting updates - Principal diagnosis assignment - Working DRG assignment for multiple diagnoses - Discharge dispositions and transfers - Coding guidelines for principal diagnosis selection - Hospital-acquired conditions - Present on admission indicators |
| Topic 6: Healthcare facility CDI program analysis | 8.33% | - Case mix index (CMI) - PEPPER data - CDI specialist productivity metrics - Patient Safety Indicators - High-frequency DRGs - CDI program forecasting - Hospital Value-Based Purchasing measures - Severity of illness and risk of mortality - CC/MCC capture - Hospital-specific financial data - Basic computer and software application skills - Tracking and trending physician, department, and hospital performance - Physician performance measurement - Publicly reported data - Provider response rates |
| Topic 7: Medical record documentation | 19.17% | - Types of physician queries - Physician query formats - Clinical indicators - When a physician query is warranted - Health record elements used for diagnosis and procedure code assignment - Compliant and noncompliant queries - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Situations in which queries are not appropriate - Translating clinical indicators into compliant queries - Documentation requiring clarification - Addressing diagnoses without clinical support - Provider role and diagnosis code assignment |
| Topic 8: Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Case mix index (CMI) - Documentation impact on IPPS reimbursement - Major complication/comorbidity (MCC) - IPPS and its updates and revisions - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Medicare contractors and their impact on CDI - Principal diagnosis and medical necessity - Medical staff and clinical staff documentation responsibilities - Coding and billing practices vulnerable to denial - Documentation and medical necessity of setting - Inpatient admission criteria and CMS Two-Midnight Rule - Complication/comorbidity (CC) |
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NEW QUESTION # 23
Under the FY 2026 Hospital Value-Based Purchasing Program, hospital performance is organized into which of the following four domains?
Answer: D
Explanation:
For FY 2026, CMS Hospital Value-Based Purchasing performance is organized into four domains: Clinical Outcomes; Person and Community Engagement; Safety; and Efficiency and Cost Reduction. CMS reports that each domain contributes to the hospital's Total Performance Score, with the FY 2026 dataset showing weighted scores for all four domains.
The Hospital VBP Program is funded by reducing participating hospitals' base operating DRG payments by
2% and redistributing the amount through value-based incentive payments according to program performance.
CDI professionals are particularly relevant to quality reporting because complete and accurate documentation can influence coded clinical information used in mortality, complications, risk adjustment, patient-safety analysis, and other quality processes. Documentation integrity should not be manipulated to improve scores; rather, the health record must accurately reflect the patient's actual severity and clinical course.
ACDIS explicitly includes Hospital VBP measures, SOI/ROM, Patient Safety Indicators, and publicly reported quality data within CCDS program-analysis competencies.
CCDS Reference Topics: Hospital VBP; quality reporting; Safety domain; Clinical Outcomes; CDI impact on publicly reported data.
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NEW QUESTION # 24
Which CMS program can reduce an eligible hospital's Medicare base operating DRG payments by as much as
3% because of excess readmissions?
Answer: C
Explanation:
The Hospital Readmissions Reduction Program (HRRP) reduces payments to applicable hospitals with excess readmissions for specified conditions and procedures. CMS calculates a payment adjustment factor ranging from 1.0 to 0.97, meaning the maximum reduction is 3%.
The adjustment applies to applicable Medicare fee-for-service base operating DRG payments rather than solely to the readmission cases themselves.
This differs from the HAC Reduction Program, which applies a 1% reduction to hospitals in the worst- performing quartile based on defined hospital-acquired-condition measures. Hospital Value-Based Purchasing uses another methodology in which 2% of participating hospitals' base operating DRG payments funds value- based incentive payments.
For CDI professionals, readmission programs demonstrate how clinical documentation can influence more than individual MS-DRG reimbursement. Accurate documentation of comorbidities, principal diagnoses, complications, discharge circumstances, and disease severity contributes to reliable risk-adjusted data.
However, CDI intervention must remain focused on clinical accuracy rather than attempting to alter readmission metrics through unsupported diagnoses.
CCDS Reference Topics: HRRP; readmissions; quality reimbursement; IPPS; risk adjustment.
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NEW QUESTION # 25
A neurologist documents acute cerebral infarction. A qualified stroke nurse records the NIH Stroke Scale score in the medical record. Which statement is MOST accurate?
Answer: C
Explanation:
ICD-10-CM permits the NIH Stroke Scale score to be reported from documentation by an appropriate clinician other than the provider responsible for establishing the diagnosis. The underlying stroke diagnosis itself must be appropriately documented by the provider.
This is similar to other specified exceptions such as BMI, pressure-ulcer stage, coma scale values, and certain additional clinical elements for which qualified non-provider documentation may support code assignment.
The exception does not mean that a stroke nurse can independently establish cerebral infarction for coding.
Rather, once the provider has documented the stroke, the nurse's formal NIHSS assessment can supply the standardized severity measurement.
This approach recognizes that specially trained clinical professionals routinely collect and document these structured measurements as part of patient care.
If multiple NIHSS values are documented, the applicable coding instructions and timing requirements should be followed rather than simply selecting the highest score because it produces a different code.
For CDI professionals, awareness of these non-provider documentation exceptions prevents unnecessary physician queries while ensuring that important severity information is not lost.
CCDS Reference Topics: NIH Stroke Scale; cerebral infarction; non-provider documentation; coding exceptions; stroke severity.
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NEW QUESTION # 26
Under the IPPS Post-Acute Care Transfer policy, which documentation element is particularly important because it can affect whether transfer-payment methodology applies?
Answer: B
Explanation:
Accurate discharge disposition is critical to application of the Post-Acute Care Transfer policy because the patient's destination after the acute inpatient stay can determine whether transfer-payment methodology applies.
Qualifying discharges to certain post-acute settings can be subject to transfer-payment rules when other criteria are met. These settings can include skilled nursing facilities and other specified post-acute arrangements, depending on applicable CMS requirements and the MS-DRG involved.
Therefore, an incorrectly documented discharge destination can affect reimbursement even when the diagnoses, procedures, and MS-DRG are otherwise accurate.
The PACT concept demonstrates why CDI and coding accuracy extend beyond diagnosis capture. The inpatient claim also relies on accurate demographic, procedural, discharge-status, and utilization information.
Dietary preference, physician experience, and the number of daily progress notes do not determine whether PACT methodology applies.
CDI specialists should recognize when conflicting documentation exists regarding whether a patient went home, to skilled nursing, rehabilitation, another acute facility, hospice, or another destination and collaborate with the appropriate departments to ensure the final record accurately reflects the actual disposition.
CCDS Reference Topics: PACT; discharge disposition; IPPS transfer rules; reimbursement; data integrity.
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NEW QUESTION # 27
A patient with a history of heart failure is admitted with severe dyspnea and bilateral lower-extremity edema.
BNP is 1,000 pg/mL and echocardiography shows an ejection fraction of 25% with left ventricular systolic dysfunction. Which diagnosis should the CDI specialist consider when constructing a clinically supported clarification query?
Answer: B
Explanation:
Acute on chronic systolic heart failure is the intended answer. This scenario is adapted from an official ACDIS CCDS sample question, which uses dyspnea, edema, elevated BNP, reduced ejection fraction, and left- ventricular dysfunction to test appropriate heart-failure clarification.
The ejection fraction of 25% and documented left ventricular systolic dysfunction support a systolic phenotype. The patient's significant dyspnea and edema are consistent with acute decompensation superimposed on the established history of heart failure. Together, these findings create a legitimate opportunity to clarify type and acuity.
The CDI specialist must nevertheless avoid diagnosing acute-on-chronic systolic failure independently. The provider determines whether the findings represent acute decompensation, chronic disease, another heart- failure phenotype, or another explanation entirely.
Option A would require evidence supporting both systolic and diastolic dysfunction. Option B fails to capture the apparent acute decompensation. Option D conflicts with the documented systolic dysfunction and reduced EF.
This question illustrates a frequent CCDS theme: translating clinical indicators into a neutral clarification opportunity rather than assigning a diagnosis based solely on test results.
CCDS Reference Topics: Heart-failure acuity and type; ejection fraction; BNP; compliant query development.
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NEW QUESTION # 28
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